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Outpatient prescribing drives unnecessary antibiotic use for CAP

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November 10, 2017

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Lauri A. Hicks

More than 70% of patients hospitalized with community-acquired pneumonia in the United States received antibiotic treatment longer than recommended, according to recent data.

Lauri A. Hicks, DO, director of the CDC’s Office of Antibiotic Stewardship, and colleagues linked this excessive treatment to outpatient prescribing upon hospital discharge.

According to the researchers, national guidelines released in 2007 by the Infectious Diseases Society of America and the American Thoracic Society recommend limiting the duration of antibiotic treatment for most community-acquired pneumonia (CAP) infections to 5 days. In rare instances, health care providers may extend therapy to 7 days, if necessary.

Hicks and colleagues conduced a retrospective cohort study to determine the average duration of therapy and most commonly used antibiotics for CAP in a nationally representative population. They gathered administrative data on 22,128 patients aged 18 to 64 years across 2,100 hospitals and 130,746 patients aged 65 years and older across 3,227 hospitals who were hospitalized with CAP and discharged in 2012 and 2013.

The median length of hospital stay was 3 days for patients aged 18 to 64 years and 4 days for patients 65 years and older. The total length of therapy, which included inpatient and outpatient prescriptions, was 9.5 days in both cohorts. More than half of the duration of therapy was due to outpatient prescribing, the researchers said. The length of outpatient antibiotic therapy was 6 days in the younger cohort and 5 days in the older cohort. Overall, 74% of patients in the younger cohort and 71% patients in the older cohort received treatment that exceeded the recommended length of therapy, resulting in 71,474 and 375,289 unnecessary days of antibiotic use, respectively. The most common antibiotics prescribed in the outpatient setting were quinolones, macrolides and first- and second-generation cephalosporins.

“These findings suggest prolonged and potentially excessive antibiotic treatment among patients hospitalized with uncomplicated CAP, and stewardship at the time of discharge may be an important target for antibiotic stewardship programs,” Hicks and colleagues wrote. “Optimizing duration of therapy, combined with optimal antibiotic selection and dosing, should help to maximize benefits to the patient while minimizing potential harms.” by Stephanie Viguers

Disclosures: The authors report no relevant financial disclosures.

itj+ Infographic

Infographic depicting unnecessary antibiotic use

itj+ Perspective

Photo of Tamar Barlam
Perspective

The study by Yi and colleagues demonstrates the widespread practice of treating CAP for longer than necessary. Most uncomplicated CAP episodes can be treated for as little as 5 days, yet approximately three-quarters of adults received almost twice that duration of treatment. Every unnecessary day of antibiotic therapy promotes the risks for adverse events such as Clostridium difficile or the selection for antibiotic resistance. The study has identified an important opportunity to improve prescribing.

Antibiotics are lifesaving drugs but they must be used judiciously. Health care providers should make themselves aware of evidence-based recommendations for treatment and follow those recommendations as appropriate for their patients. Antibiotic stewardship seeks to improve prescription of the right drug, at the right dose, at the right time, for the right duration. Health care providers should only give antibiotics when necessary and treat for the amount of time needed to cure the infection and no longer.

Tamar F. Barlam, MD

Associate professor of medicine
Boston University School of Medicine
Infectious diseases physician
Boston Medical Center

Disclosure: Barlam reports no relevant financial disclosures.